POS0690 SYSTEMATIC LITERATURE REVIEW: WHICH ROUTE AND DOSE OF CORTICOSTEROID IS MOST EFFECTIVE IN INDUCING REMISSION IN EARLY RHEUMATOID ARTHRITIS?
Authors: L. Parker, N. Gullick
Journal: Annals of the Rheumatic Diseases (2022)

Background Current NICE guidance for rheumatoid arthritis (RA) states that glucocorticoids may be used for bridging therapy and to rapidly decrease inflammation in acute flares 1 . However, a recommended route and dosage is not specified, and variation has been observed between individual departments as to whether or not steroids are administered 2 . Glucocorticoids are associated with adverse events that can be severe, leading to a strong recommendation by the American College of Rheumatology to avoid long term use 3 . It is therefore important to ascertain the efficacy of available routes and dosages of glucocorticoids to weigh against these risks. Objectives This review aimed to ascertain the optimum route and dose of corticosteroid for adults with early RA. Methods Papers included were full text, English language, randomised controlled trials that fulfilled the PICO criteria. The population was defined as adults with early RA with onset &lt;2 years, the intervention corticosteroids of any route or dose, the comparator conventional DMARDs or placebo, and the primary outcome remission. Functional improvement and X ray progression were considered as secondary outcomes. MEDLINE, Embase, Web of Science and Cochrane Central were searched. Screening of results and extracted data was carried out by both reviewers. During data extraction, outcomes were rounded to timepoints of 3, 6 and 12 months, and steroid doses were stratified into low (up to 10mg/day prednisolone or equivalent), medium (15-30mg) and high (&gt;30mg). Meta-analyses were carried out in RevMan 5.4 when 3 or more studies measured the same outcome at the same dose and route. A funnel plot was generated to check for publication bias. Results Three papers measured DAS28 remission rate at 1 year, comparing DMARDs only to DMARDs plus low dose oral steroids. The Forest plot for this meta-analysis is shown in Figure 1. As I 2 = 0%, a fixed effect method was used. This shows an odds ratio (OR) of 1.73 (95% CI 1.25, 2.39) favouring low dose steroids in addition to DMARDs. Meta-analyses were also possible for HAQ at 1 year, and mean DAS28 at 1 year, comparing DMARDs alone to DMARDs plus low dose steroids. Both analyses favoured steroids; for HAQ scores the standardised mean difference (SMD) was -0.69 (95% CI -1.66, 0.29), and for DAS28 the SMD was -0.36 (95% CI -0.58, -0.15). At 3 and 6 months there was a lack of available data for meta-analyses. Figure 1. Forest plot showing the OR of DAS28 remission with low dose steroids and conventional DMARDs vs DMARDs only Conclusion At 1 year, remission and improvement in function appear more likely if low dose steroids are used. Due to a lack of available data, non-oral routes, higher doses and X ray progression could not be analysed. Studies were not designed to detect differences in adverse events. This highlights the need for further clinical research into steroid efficacy in early RA, as the meta-analyses suggest that glucocorticoids may be more effective in inducing remission in early disease than conventional DMARDs alone. References [1]National Institute for Health and Care Excellence. Rheumatoid arthritis in adults: management . https://www.nice.org.uk/guidance/ng100/chapter/Recommendations [2]Yates et al. Rheumatology . 2020;59: 2035-42. [3]Fraenkel et al. Arthritis Care &amp; Research . 2021;73: 924-39. Disclosure of Interests None declared